2016-06-30-AMGH Employee Handbook

Employee
Handbook
You Can Count on Me

WELCOME TO AMGH!
As a new member of the AMGH team, this booklet was created to assist you in accessing
information you will need as you transition into our team.
This document contains an overview of the practices and policies at AMGH. You will find more
detailed information in Docushare, our Internal Intranet. (see page 39 for more about Docushare).
TABLE OF CONTENTS
A WARM WELCOME TO AMGH! 4 & 5
Vision, Mission, and Values 6
HOSPITAL PROFILE 8
Alexandra Marine and General Hospital Executive Leadership Team 9
Board of Directors 9
STANDARDS FOR BEHAVIOURS OF EXCELLENCE POLICY 10
Policy 10
Standards for Personal Behavior 10
Standards for Professional Behavior 11
ACCREDITATION 12
AMGH INVOLVEMENT 13
ATTENDANCE MANAGEMENT 14
Sick Time Pay 14
BENEFITS 16
Benefits / In-lieu 16
Employee and Family Assistance Program (EFAP) 16
Pension 17
Statutory Holidays 17
Vacation 17
DEVELOPMENT 18
College Registration 18
Skill Review Days 18
Training 18
EMERGENCY FIRE CODES 19
Employee Perks 20
Perkopolis 20
M2M Discount Program 20
INFECTION CONTROL-ROUTINE PRACTICES AND ADDITIONAL PRECAUTIONS 21
INFECTION PREVENTION AND CONTROL 22
Influenza Vaccine and Policy 22
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TABLE OF CONTENTS
Hand Hygiene 22
Personal Protective Equipment – PPE 23
Routine Practices 23
IT SERVICES 24
Computer / Email / Internet Usage 24
Employee Intranet 24
Forms / Templates 25
Meditech 25
ServiceAnyware 25
KEY CONTACTS 26
LEGAL CLAIMS 27
Legal Claims and Property Damage 27
Reporting of Potential or Actual Medical – Legal Claims 27
OCCUPATIONAL HEALTH AND SAFETY/SECURITY 28 & 29
Mandatory Safety Training 29
Risk (RL6) Reporting System 29
Smoking 29
Video Security System 29
PARTNER ORGANIZATIONS 30
Maitland Valley Family Health Team (MVFHT) 30
Community Care Access Centre 30
PERFORMANCE MANAGEMENT 31
ROADMAP TO EXCELLENCE 32
Clinical Services Plan 32
AIDET 33
Communication Boards 34
Rounding 35
Stoplight Report 35
Strategic Plan 36
SERVICES 37 & 38
STARTING YOUR CAREER AT AMGH 39
Docushare 39
Dress Code 39
VIOLENCE / HARASSMENT 41
Harassment 41
Violence Prevention in the Workplace 41
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A WARM WELCOME TO AMGH!
On behalf of the staff, physicians, and volunteers of the Alexandra Marine and General Hospital
(AMGH), We are delighted to welcome you to our organization! This handbook is to help you find
information you need for your journey with AMGH. We encourage you to find out even more about
our mission, vision and values to understand what guides us, as well as the services and programs
we offer by visiting our website www.amgh.ca. We are so very glad you have chosen Alexandra
Marine and General Hospital.
The Alexandra Marine and General Hospital has a proud tradition of more than 100 years of
exceptional care. As a seasonal community that resides in the heart of cottage country on the shores
of Lake Huron, we offer full service healthcare not only to the communities we serve year round, but
to the many visitors who frequent our beautiful area.
The patient and the family experience is at the heart of everything we do. With a focused
commitment to provide compassionate, safe, and high quality care to those we serve, and as the
largest healthcare organization in the County, the Alexandra Marine and General Hospital is home to
a robust, full service acute care hospital and the only inpatient adult psychiatric facility and
withdrawal beds in Huron County. Well beyond the borders of the hospital and as an integrated
health system, we provide community mental health and addiction services including intensive case
management, and crisis response across two counties and outpatient onsite counselling and group
work across five community sites.
AMGH is just one of five rural hospitals across the province to be designated a telestroke site and
the only hospital in the southwest LHIN. The ability to diagnose and immediately treat symptoms
quickly through telehealth access to the expertise of neurologists and cardiologists at large urban
hospitals substantially reduces the devastating impact of stroke. As well, we host a number of
regional programs such as onsite renal dialysis in collaboration with London; the only obstetrics
service in Huron County; and a regional eating disorders program. AMGH is able to offer a
well-rounded range of specialized outpatient services such as orthopedics, internal medicine,
pediatrics, diabetes education, endocrinology, gynecology, and plastic surgery. We are very
fortunate to work collaboratively with a number of exceptional service partners in the southwest to
bring (and keep) healthcare services closer to home and to streamline the delivery of service to
better meet our patient and client needs.
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At AMGH, the staff and physicians are always hard at work to not only attain best practice but to
ensure the efficient and effective use of the limited financial and human resources available to us.
It’s often very challenging with needs increasing and resources diminishing, however we are
committed to the journey. As a fully ‘accredited with commendation’ organization, we are the gold
standard for high quality as determined by Accreditation Canada. AMGH is cited for our
progressiveness, innovation, focus on leadership and continuous learning, and the many
achievements that demonstrate a high quality of services. With a strong patient focus, and a
serious commitment to organizational alignment, individual accountability and exceptional
leadership throughout the organization, AMGH has achieved a rating of 100% of patients who
would highly recommend using this hospital. There have been parallel achievements in safety and
quality with hand hygiene compliance at 95%, alternate level of care beds being reduced by 10%,
and 30-day patient re-admissions being reduced to a low of 3.2%. In 2014, AMGH has realized a
50% decrease in sick time through staff engagement and heightened accountability, and achieved
an influenza immunization record of 90% for staff and physicians.
With a newly refreshed mission “You Can Count On Me” that speaks to the passion and
commitment we hold ourselves to, and the belief that patients and their families expect and
deserve exceptional quality of care, respect, and compassion each and every time they turn to us
for their care. We believe this mission also speaks to the standards of excellence that guide us in
how we treat one another in the workplace and the values that we live in our choices and in our
behaviors. We strive to not only meet but exceed those expectations even under at times the
most challenging of circumstances. It’s because we truly care – we care to make a difference –
and based on the feedback from those we serve and from our staff and physicians, we do!
Thank you for making this important career decision to join our team. Your contributions as a
member to AMGH will be critical to our ongoing success!
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OUR FRAMEWORK
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HOSPITAL PROFILE
Alexandra Marine and General Hospital (AMGH) provides health care services in Huron County to
the community of Goderich and several surrounding municipalities representing a catchment area
of approximately of 25,000 people.
The AMGH is a full service community hospital providing on-call coverage for internal medicine,
general surgery, diagnostic imaging, anaesthesia, and obstetrics. In addition, the Emergency
Department has a physician on duty twenty-four hours a day, seven days per week. AMGH is the
largest provider of hospital services in Huron County which includes the delivery of primary care, a
range of secondary level acute and complex continuing care to its broad catchment population.
The Hospital is an active treatment facility operated under the direction of a twelve member Board
of Directors. AMGH currently operates forty-two (42) beds providing acute, long-term, psychiatric,
emergency and ambulatory care and is operating under a four-year accreditation award granted in
2013.
It is a Schedule 1 Facility with a twenty bed inpatient psychiatric unit that provides care for all of
Huron County as well as providing services for some bordering communities in Bruce, Grey and
Perth Counties. The Hospital also offers full-time community psychiatric outpatient centers for the
Towns of Goderich, Clinton, Seaforth and Wingham. In addition to these community programs, the
Hospital provides the Regional Intensive Case Management Program serving mentally ill patients
throughout Huron and Perth Counties.
Medical practitioners on active staff include two general surgeons, four psychiatrists, one internist,
one OB/GYN and thirteen family doctors. Four general practitioner anaesthetists provide
anaesthesia coverage. These physicians, supported by visiting specialists primarily from London
and Stratford, provide services for a wide range of outpatient clinics including gastroenterology,
general surgery, gerontology, gynaecology, internal medicine/cardiology, neurology, obstetrics,
orthopaedics, paediatrics, and respirology/allergy. Three general practitioner obstetricians provide
obstetrical service.
Other community services provided at AMGH include cardiology investigations, a wide range of
diagnostic imaging procedures, laboratory, diabetic education, nutrition, occupational therapy,
physiotherapy, speech and language pathology, pulmonary function testing, Holter, stress testing,
ECG, and social work. An active ambulatory care program is maintained and includes day surgery
and outpatient paediatrics. Those patients in need of more specialized care and treatment are
primarily referred to the tertiary care facilities in London.
The Board at Alexandra Marine and General Hospital is committed to patient safety and in
fostering a safe environment for patients and their families. In the interest of maintaining its high
quality of care and its practice of continuous improvement, the Board wants unsafe conditions and
practices eliminated. To that end, the Board has identified patient safety as one of its strategic
directions with objectives and an action plan to ensure its implementation.
The Hospital employs approximately 250 staff (part and full-time) and has an operating budget of
approximately $19.5 million.
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Alexandra Marine and General Hospital
Executive Leadership Team:
Vacant, Chief Executive Officer
Samantha Marsh, Chief Nursing Executive / Vice President Clinical Services
Jimmy Trieu, Chief Information Officer / Vice President Corporate Services
Sulav Pant, Director of Finance /Health Records
Peggy Byrne-Carter, Human Resources Advisor
Board of Directors
Alexandra Marine and General Hospital's Board of Directors includes a number of dedicated
community residents. These people volunteer their time to provide governance to the hospital’s
activities, work with the health partners in our communities, and offer expertise in a number of areas
to support the hospital.
Pictured left to right
Back Row: Matthew Armstrong, Myles Murdock, Dr .Julie Moore, Dennis Schmidt, Glen McNeil, Dr .Dan Noel,
Pamela Somers, Peter Shephard, Allan Ball,
Front Row: Mike Niglas, Jolene Duncan, Barb Major-McEwan (Board Chair), Karen Davis, Richard Bedard and Rowland Howe.
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STANDARDS FOR BEHAVIOURS OF EXCELLENCE POLICY
POLICY
The Alexandra Marine and General Hospital has an established code of conduct referred to as
“Standards for Behaviors of Excellence”. This code defines the personal and professional
standards of conduct and acceptable behavior for all people carrying out the assigned
responsibilities of the organization at all of its service sites. It is the responsibility of individuals to
act in a manner consistent with these standards, and to support this code of conduct by holding
others accountable to the standards.
The Standards of Behaviours of Excellence ensures a positive, supportive and safe environment
for all patients, clients, and visitors, as well as the employees, physicians, contractors, volunteers,
students, auxiliary, Foundation employees, and Board members. It is expected that all share in the
preserving and enhancing of the organization’s values and principles.
To achieve this, all people who carry out assigned responsibilities within the organization will be
expected to conduct themselves in a respectful, courteous, and professional manner and will be
asked to sign a Commitment Agreement that will govern their future conduct and performance.
Be Accountable
Be Collaborative
Be Compassionate
Be Innovative
Be Honest, Fair and Transparent
Be Committed to Quality Improvement and Learning
Be Respectful
Standards for Personal Behaviour
I will treat others as I would want to be treated.
I will show a positive and helpful attitude.
I will adhere to the organizational values of Accountability, Collaboration, Compassion,
Innovation, Integrity, Quality, and Respect in every action, behaviour and decision.
I will be honest, trustworthy, reliable, dependable, professional, presentable and punctual in
all of my workplace activities.
I will collaborate with Leadership by taking direction and correction respectfully and by being
an active contributor in offering ideas, suggestions, advice, and constructive criticism in an
engaged and respectful manner.
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Standards for Professional Behaviour
It is recognized that there must be rules and regulations to govern the activities involved in the
operation of an organization. The following standards have been developed to protect the rights and
privileges of you and others. Infraction of the following may be grounds for disciplinary actions up to
and including termination, reporting to a professional body, or suspension of privileges.
I will present myself in a professional manner at all times.
I will conduct myself in a way that respects and safeguards the organization’s assets including
property.
I will perform the work assigned at my designated work location and comply with written or
verbal instructions. I recognize that failure to do so may be considered insubordination.
I will comply with all policies and procedures, and perform assigned duties to ensure quality of
care and personal safety and the safety of others.
I will report to Occupational Health all known communicable or infectious diseases which may
endanger anyone associated with this organization.
I will provide truthful testimony when accidents (including WSIB claims) and incidents are
being investigated, providing information in a truthful, open, and honest manner and without
compromising the facts.
I will show diligence to avoid “Time Theft” at work which is when an employee accepts pay
from their employer for work that they have not actually done or for time they have not actually
put into their work.
Examples of time theft are when staff take too much time on their given breaks (i.e.
leaving for break early and coming back from break late) or when staff take more breaks
in a shift than they are allowed. It is associated with staff who spend parts of their
workday making and taking personal calls or spend time checking and sending email that
is non-work related during paid work time. It is also associated with staff who use
technology for non-work related purposes such as browsing the internet, spending time
on social networking sites, and texting during work hours.
I will report all types of absences (such as appointments or sick time) that will necessitate any
absence from the workplace during paid work hours to the in-charge supervisor in my
department.
I will report for work fit for duty during work time including on-call and not possess any
intoxicants while on AMGH property or during working hours.
I will provide quality patient care to patients and visitors without any acceptance of personal
gratuities including money and gifts of any nature.
I will always ensure a high level of discretion, confidentiality, and privacy for those in my care,
for my coworkers, and for the organization as a whole.
I will not conduct personal business during paid work time.
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ACCREDITATION
What is an Accreditation Survey?
An accreditation survey is a process by which our practices and procedures are reviewed by
other health care professionals to ensure the care and services we provide are focused on
quality and safety according to nationally recognized standards. This is our opportunity to show
that we provide consistent, high quality, safe care.
The accreditation cycle covers a four year period with the on-site survey generally occurring in
the fall. While the onsite survey occurs once every four years, ensuring our care/service meets
the standards of excellence is a continuous process.
Why do we do this?
A certificate from Accreditation Canada means we have been reviewed by our peers, have met
or bettered national standards of excellence and that we continue to strive for high quality in our
care and services.
How does the Accreditation process work?
Care / service areas review the standards for their area and rate the performance of their area
according to these standards. The ratings are collated into a report that shows which standards
are being met and which ones need some work. Care / service areas develop and execute
action plans to ensure unmet standards are addressed. The onsite survey is our opportunity to
showcase our care / service to the Accreditation Canada surveyors. Accreditation Canada
determines our accreditation award. Care / service areas review the accreditation award to
determine where improvements can be made and develop and execute action plans.
How can you get involved?
Talk to your manager about becoming involved.
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AMGH INVOLVEMENT
AMGH Auxiliary
The Auxiliary is the organization’s volunteer group. The group has approximately 75 members,
many of whom volunteer in many areas of the hospital. The areas that receive volunteer services
that are provided five days a week are: day surgery/admitting, flower care, pre-natal, palliative care
and the speech clinic.
The Auxiliary undertakes a number of fundraising projects throughout the year such as Gift Shop,
raffles, lunch/card party, tag day and hot dog days. We are very proud of our strong volunteer
group!
AMGH Events
There are many fun, interactive events that take place at AMGH and in the community. There are
days every year devoted to different departments and you can always count on fun activities being
arranged which usually include great prizes. For staff appreciation, annually we have a Staff
Appreciation Reception, Staff Appreciation lunch in June, and Christmas lunch that includes all the
trimmings. We hold contests and activities for other holidays throughout the year so there is
always something fun going on at AMGH you can get involved in!
AMGH Hospital Foundation
The Alexandra Marine & General Hospital Foundation is a non-profit charitable foundation
established to raise funds on behalf of AMGH. The Foundation is a separate organization and not
under the Hospital’s management. It supports the goals of the Hospital of providing quality health
care by inviting the community to donate funds, in order that appropriate equipment, human and
health care resources are made available to Goderich and area communities. The Foundation also
hosts many fundraising events throughout the year. The Foundation office is located in Room 110
on the first floor.
Committees
There are many committees at AMGH that you may be asked to join where you can provide input
and participation. The committees that you are asked to join will be a fit with your position at the
organization. Some current committees are: Emergency Preparedness committee, Joint Health
and Safety Committee, and Privacy Committee. If you are interested in joining a committee speak
with your manager.
Staff Association
This Association collects by payroll deduction, a modest yearly contribution of $24.00 from those
employees who sign up as members. The Association is a staff to staff acknowledgement of
members’ life events and has established set guidelines for use of funds for the following: sick
leave, bereavement, births, weddings, retirements and voluntary terminations. The membership and
fund were established to ensure a fair and respectful way to acknowledge staff by being consistent
in applying the same guidelines to all members. Any surplus money each year is used to finance
other forms of social activities for Hospital staff. Members of the Association also receive reduced or
free cost on the Staff Appreciation Reception tickets each year.
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ATTENDANCE MANAGEMENT
AMGH is committed to the care and well-being of our patients, continuous quality improvement
and the professionalism of our staff. In keeping with this commitment, it is recognized that regular
attendance by all employees is an expectation at AMGH and is essential to our patients and the
hospital. Regular attendance is a fundamental obligation of employment.
The AMGH Attendance Management policy applies to all full-time and part-time employees. This
policy is based on increased staff awareness regarding the need to be at work on a regular basis;
providing feedback to employees regarding attendance, and offering assistance to those
employees who are having difficulty maintaining regular attendance. The policy provides a fair
and consistent approach with respect to frequent and excessive absenteeism as well as
recognition for excellent attendance.
The organization’s threshold for sick time is 52.5 hours in a rolling 12 month period. If a staff
member reaches or exceeds this threshold, the member will enter the attendance management
program which begins with a meeting with the staff member’s manager, Occupational Health and
Human Resources.
Sick Time Pay
Part-time employees are paid in lieu of sick time as part of their benefits in lieu. Full-time staff are
covered by the Hospitals of Ontario Disability Income Plan (HOODIP). The first 15 weeks of sick
time is considered Short Term Disability (STD) and is fully funded by the organization.
If a member is sick longer than 15 weeks, he/she would move to long term disability (LTD) which
consists of 15 weeks of Employment Insurance Sick Leave and if progresses then the member
would apply for LTD benefits through the benefits provider. STD is paid at the following levels:
At least 3 months of service – 66.67% of regular earnings
At least 1 year of service – 70% of regular earnings
At least 2 years of service – 80% of regular earnings
At least 3 years of service – 90% of regular earnings
At least 4 years of service – 100% of regular earnings
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BENEFITS
Benefits / In-lieu
Full-time:
Full time staff are eligible for dental, extended health, automatic life insurance (two times salary)
and optional life insurance. Staff must enroll within thirty (30) days of hire into a full-time position
to be eligible.
Part-time:
Part-time staff are paid a percentage in lieu of benefits according to policy or collective agreement.
Employee and Family Assistance Program (EFAP)
All employees and their families have free access to our confidential Employee and Family
Assistance Program from our provider, Homewood Human Solutions. The services our EFAP
provides include counselling services, life balance services, career smart services and online
resources. Homewood also sends monthly wellness bulletins and provides on-site wellness
sessions. Services provided are confidential. The Hospital will never receive names of persons
utilizing EFAP. EFAP can be contacted 24-7 at 1.800.265.8310 24 hours a day/7 days a week.
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Pension
Our pension plan, HOOPP (Healthcare of Ontario Pension Plan), provides a Defined Benefit (DB)
plan which pays out a set pension amount every month based on a member’s length of service
and best 5 consecutive years of earnings.
HOOPP is fully funded at 114% and has 51.6 Billion in Net Assets making it a secure investment
for our staff.
See Your Future Now
When starting a new position, retirement is probably the last thing on your mind. But it’s exactly
the right time to start planting roots for your future. The benefits of HOOPP are that it offers
flexibility, portability and secure growth. And the sooner you join HOOPP, the more growth you
can expect.
Full-time staff are eligible on their start date; part-time staff are eligible to enroll in the January
following their first calendar year that they work 700 hours. We strongly encourage you to enroll in
the pension plan.
If you have any questions about your HOOPP pension, please contact Human Resources at
extension 5720 or Payroll at extension 5703. You can also access information online at
www.hoopp.com.
Statutory Holidays
The Statutory Holidays list will be posted in Docushare every Fall for the following year. The
hospital observes the following statutory holidays:
New Year’s Day Civic Holiday
Family Day
Labour Day
Good Friday
Thanksgiving Day
Easter Monday
Remembrance Day
Victoria Day
Christmas Day
Canada Day
Boxing Day
Vacation
Full-time:
Vacation is earned by hours worked; vacation is updated on each payday. If, for example, you are
entitled to four weeks vacation, you would earn 4.77 hours of vacation each payday. The
organization’s Overtime, Additional Hours and Banked Time Policy outlines the maximum hours
that an employee can have banked at any time.
Part-time:
Part-time staff are paid a percentage in lieu of vacation according to how many weeks they are
eligible for; part-time staff must take the number of weeks of vacation per year for which they are
eligible.
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DEVELOPMENT
College Registration
If you belong to a College, it is imperative that you give an electronic copy of your annual
registration to your manager each year.
Skill Review Days
As part of a commitment to ongoing learning for our staff, Skill Review Days are scheduled
annually. Generally held in the spring, these are two days set aside to allow staff to review skills,
recertify point of care testing and hear new ideas. Many of these events are conducted by our in
house experts with the remaining led by individuals representing our vendors or services
available in the community. Each year, a number of events are determined as mandatory,
mainly for the nursing staff, while a great many others are open to anyone who wishes to attend.
If you are interested in taking part by conducting a learning session, please speak with your
Manager.
Training
Training at the organization can be online, print or in session, on or off site. There are
mandatory and non-mandatory training opportunities at the organization. Any mandatory
training will be announced early in the year and is usually due by December 31 st of each year;
most mandatory training is completed on-line. Other mandatory training may arise due to
legislative changes and will be communicated with staff. Any staff member who fails to
complete mandatory training before the deadlines will not be scheduled for shifts until it has
been completed.
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To overhead page an emergency code
Call 1111 and you will be immediately be transferred to switchboard
who will announce your code overhead
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EMPLOYEE PERKS
Perkopolis
AMGH is a registered company with Perkopolis. The thrill of theatre, the magic of movies, family
attractions and spectacular sports - that is Perkopolis & so much more. Add savings on hotels,
apparel, home services, automotive, travel, that is what Perkopolis is all about. To sign up for
Perkopolis:
1. Go to www.perkopolis.com
2. Click on “Not yet a member?” to create your profile & password.
3. Your member ID = AMGHPERKS
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INFECTION CONTROL-ROUTINE PRACTICES
AND ADDITIONAL PRECAUTIONS
Routine Practices and Additional Precautions continue to be the terms used across Canada when
talking about infection control precautions.
Routine Practices
Routine Practices are measures to be taken when caring for all clients at all times. They include:
Risk Assessment
Hand Hygiene
Appropriate Use of Personal Protective Equipment
Environmental Controls
Immunization
Health Workplace Policies
Respiratory Etiquette
Education and Training
Additional Precautions are used in addition to Routine Practices when an individual has a known or
suspected organism.
There are three categories of Additional Precautions:
Airborne precautions
Droplet precautions
Contact precautions
Any health care worker has the ability to place any client in Additional Precautions without a
physician’s order.
Disease can be transmitted in more than one way. If this is the case, Droplet, Airborne and
Contact may need to be combined as indicated. For example, most viral respiratory diseases are
spread through the droplet and contact route, so a patient with a viral respiratory illness in the
contagious stage, should be cared for using Droplet and Contact Precautions.
The yellow isolation carts contain all of the necessary Personal Protective Equipment (PPE) that is
needed when a patient is placed in Additional Precautions. These carts also contain the signs that
are placed on the patient’s door showing which PPE is required before entering the room.
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INFECTION PREVENTION AND CONTROL
Influenza Vaccine and Policy
Patient Safety: influenza vaccine is determined to be the primary method of protection against
contracting and transmitting the influenza virus. Healthcare workers (HCWs) have the potential for
acquiring and transmitting influenza to those under their care during seasonal community activity
of influenza virus. All Healthcare Workers are at risk to the hazard of influenza infection due to the
risk of exposure to infected persons in the healthcare workplace. All staff and volunteers are
required to be immunized by December 1st of each year. Any staff or volunteer who is not
immunized by this date must wear a protective mask within 6 feet of a patient while at work and
must do so for the duration of the flu season. AMGH will provide an identifier for those staff who
have received the vaccine. The influenza vaccine is available from the Occupational Health
Nurse, extension 5721
Hand Hygiene
Hand Hygiene is the responsibility of all individuals involved in healthcare. Hand hygiene refers to
removing or killing microorganisms on hands as well as maintaining good skin integrity. There are
two methods of removing/killing microorganisms on hands; washing with soap and running water
or using an alcohol-based hand rub. Generally, the focus is on microorganism that have been
picked up by contact with patients/healthcare provider, contaminated equipment, or the
environment (transient or contamination bacteria). Effective hand hygiene kills or removes
microorganisms on the skin and maintains hand health. Results are shared with all staff and
posted on the Infection Prevention and Control dashboard monthly.
Hand hygiene audits are completed on a regular basis. It is mandatory that all staff follow hand
hygiene procedures.
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Personal Protective Equipment – PPE
Routine Practices include recommendations to use Personal Protective Equipment (PPE)
whenever a healthcare worker might be exposed to potentially contaminated fluids, surfaces, or
items in the health care environment.
Routine Practices
Routine Practices include the concept that healthcare workers should use a mask and eye
protection during procedures and care activities that might generate splashes or sprays of blood,
body fluids, secretions and excretions. This PPE should also be worn when within two meters of a
coughing/sneezing patient. Another example of an appropriate use of mask and eye protection is
that of a staff member wearing a gown, mask, eye protection, and gloves when cleaning equipment
that is contaminated and may cause splashes or spraying of fluids. The physical scrubbing of
contaminated equipment can generate splashes of potentially infectious agents so the employee
needs to protect their mucous membranes from the potential spray of contaminated fluid.
Routine Practices state that a staff member should also wear a gown when it is anticipated that a
procedure or care activity is likely to generate splashes or sprays of blood, body fluids, secretions
and excretions. In addition to the regular isolation gowns there are also fluid resistant gowns that
can be found in the yellow isolation carts, they can also be ordered from Stores if they are not
found in the clean utility room. Gloves should be worn whenever there is a risk that hands may
come into contact with blood, body fluids, secretions, excretions, mucous membranes, non-intact
skin, or contaminated surfaces or objects. Hands must be cleaned before and after donning the
gloves.
PPE can be found in the clean utility rooms and in the yellow isolation carts.
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IT SERVICES
Computer / Email / Internet Usage
All Staff must review all IT access and usage policies and sign the Systems Access Agreement. By
doing so, staff agree that:
I understand that I am accountable for, and accept responsibility for, all activities carried out
under my access codes;
I will report to Management or Information Systems immediately if I have reason to believe my
User ID and/or Password were revealed or compromised;
I accept responsibility for the accuracy and appropriateness of data that I enter into the
organization’s patient-care systems;
I understand that I am required to log off patient-care systems when I have completed my task
and that I should not leave an open access unattended;
I will only access information required to provide care to patients or as directly required in the
performance of my duties. If I have more than one User ID, I understand that any given time, I
must only use the User ID specific to the role and function that I am performing;
I have read the Alexandra Marine and General Hospital’s Acceptable Use of Information
Technology Resources policy and the E-mail policy. I will adhere to the policy and procedure
that applies to staff members who use network resources including the Internet, e-mail and
other related activities involving hospital computing.
I will respect the confidentiality and privacy of individuals to whose records I have been given
access in compliance with the requirements of the Ontario Personal Health Information
Protection Act;
I have completed, or agree to complete, any training requirements related to my access to the
patient-care systems at the hospital; and
I have read, understand and accept the above statements. I understand that failure to comply
with these statements may be cause for disciplinary action up to and including termination of
employment/contract or loss of appointment or affiliation with the organization.
It is important to note that all emails are only retained for a period of 6 months. After this time, emails
older than 6 months will automatically be deleted from your account. If you wish to save an email,
please save to a folder in your drive.
Employee Intranet
The employee intranet at AMGH is called Docushare. All documents are contained online and you
will be able to access all information related to AMGH in Docushare. Examples of information
contained in Docushare are: memos to staff, AMGH newsletter (called “AMGH Happenings”),
calenders outlining admin on call rotation, vacations and meeting room bookings, internal job
postings and policies just to name a few. For more information, regarding Docushare, please see
page 39.
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Forms / Templates
Forms and templates are located in Docushare. These include templates for letterhead and
powerpoint presentations as well as educational assistance forms and expense forms.
Meditech
Meditech is the organization’s current computer program for patient care, records, payroll, accounts
payable and receivable. Meditech training will be provided by a Meditech SuperUser on site.
ServiceAnyware
Service Anyware is a quick, accessible, and user friendly method for AMGH staff to request service
from the Maintenance and IT departments. All computers have a shortcut to ServiceAnyware.com.
The login page has been setup so staff are automatically using logged in their Windows username
and password. For PACS support, please see Colleen Maguire.
25

KEY CONTACTS
Your manager is a valuable resource for you as you start your journey at AMGH. Other key
contacts you need to be aware of are:
Member’s Designation Member’s Name Extension
CEO Vacant 5711
Vice President Clinical Services Samantha Marsh 5715
Vice President/Chief Information
Officer
Manger of Financial Services and
Health Records
Jimmy Trieu 5713
Sulav Pant 5704
Manager of ER, Ambulatory Care, Lori Merner 5718
OR, MDRU and Dialysis
Manager of Diagnostic Imaging Heather Robinson 5480
Manager of Laboratory,
Cardiorespiratory
Clinical Lead of Community
Psychiatric Services
Robert Kerekes 5455
Lynn Higgs 519-524-8316 Ext 5751
Manager of Support Services Meribeth Vlemmix 5722
Privacy Officer
Sulav Pant/Mary Buchannan 5704/5400
Smith
Human Resources Peggy Byrne Carter 5720
Physician Recruitment Gwen Devereaux 5724
Foundation Foundation Office 524-524-8508
Executive Assistant to the CEO-
Interim
Alana Ross 5712
Administrative Assistant-Nursing Jennifer Yule 5716
Administrative Assistant-Corporate Crystal Dalton 5714
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LEGAL CLAIMS
Legal Claims and Property Damage
The Chief Information Officer is responsible for legal claims and property damage claims (or
admin on call in absence)
RL6 Risk Monitor is used to document all events
In event Police (or other body) presents a warrant, statement of claim, notice of action, or other
documentation, direct them to the Chief Information Officer (Admin on Call in CIO Absence)
Reporting of Potential or Actual Medical –Legal Claims
All staff are responsible for notifying their Clinical Lead/Manager/Vice President of any event
that could lead to a medical-legal claim.
The persons identifying the risk/event is responsible to complete the appropriate Incident
Report as soon as possible and submit it to their Manager/Vice President.
The Clinical Lead/Manager is responsible for notifying the Vice President s/he reports to, the
Program’s Physician’s Lead, if appropriate, and the Vice President responsible for Risk
Management.
The Chief Information Officer (Admin on Call in CIO Absence) is responsible for notifying the
Corporation’s Insurers and Liaising with Insurance Adjusters, Legal Counsel and any staff or
physicians that were involved.
27

OCCUPATIONAL HEALTH AND SAFETY/SECURITY
Overall responsibility for Security rests with the Manager, Support Services.
Assistance in Emergency Situations
If you have a condition or disability you feel may impact your ability to respond to an Emergency
situation (codes) please inform your supervisor and Occupational Health.
We have a process and procedure to review your limitations and needs and ensure we have plans in
place within your department for these situations. You can find more about this in Docushare:
Polices, Procedures and Forms, Polices and Forms – Administration, Accessibly Policies, and
Accessibility Workplace Emergency Response Plans for Staff with Disabilities.
Controlled Access/ Keys
Some departments issue keys to staff. If this is the case, you will be assigned a key by the Manager
of Support Services- this is your responsibility and you are required to return the key if employment
is terminated. All staff wear photo ID. This is also a means for access to certain areas. Staff
generally enter the facility through the side doors which are always locked, your ID will allow you
entry. Several departments /areas are locked at all times and staff gain access with their ID. Staff
locker rooms and washrooms in basement are also on controlled access and all staff have access
with their ID badge. Some areas have restricted access and only those working in that area have
privileges to enter with ID badge. If you lose your badge you will be charged an administration fee to
replace it.
Ergonomics / Physical Demands Analysis
We are a very fortunate organization to have an on-site Physiotherapy department. Our
physiotherapist prepares Physical Demands Analyses for each position at the organization which
entails looking at job function and making changes that meet ergonomic requirements.
28

Safe Patient Handling—No Lift Policy
AMGH will ensure that its patients are cared for safely, while maintaining a safe work environment
for workers. To achieve this, AMGH has adopted a no-lift policy for patient handling. Transferring
and lifting must be done using appropriate and proper equipment, technique and body mechanics.
The policy can be found in Docushare.
Mandatory Safety Training
Mandatory safety training will be outlined by your manager. Training will include safety training
during general orientation as well as annual training as deemed necessary specific to your position
and the organization.
RL6 Risk Monitor Reporting System
It is the expectation that any staff member who witnesses, discovers or is involved in an incident will
complete an incident report. Incident reports are filed electronically via the RL6: Risk Reporting
System accessible from the Docushare home page. A user ID and password are required to access
and are assigned by the Quality/Risk and Patient Safety Coordinator. Education regarding the use
of the risk reporting system will be arranged during your orientation period.
Smoking
Smoking is not allowed in the building or on the organization’s property; this includes the use of
e-cigarettes.
Video Security System
All entrances to the building have video surveillance. Video surveillance is active throughout much
of the building and as such, most day to day activity is captured on video.
29

PARTNER ORGANIZATIONS
Maitland Valley Family Health Team (MVFHT)
The MVFHT provides primary care in a team based approach to families and individuals who are
rostered. Rostered patients are able to access services such as physicians, nurse practitioners,
diabetes education, clinical nutrition, pharmacist, social worker and a psychologist. There is a blood
collection center in the building that is open to the general public. The building is owned by the Town
of Goderich and is operated independently from AMGH. The MVFHT has their own separate
medical record (which is not viewable by AMGH staff). Some hospital information is shared
electronically with the MVFHT (such as lab, medical imaging and discharge notes).
Southwest Community Care Access Centre (CCAC)
The Southwest Community Care Access Centre gets people the care they need to stay well, heal at
home and stay safely in their homes longer. When home is no longer an option, they help people
make the transition to other living arrangements. CCAC is on site at AMGH and can be contacted at
extension 5642.
30

PEN POLICY
Alexandra Marine & General Hospital (AMGH) has a Documentation and Writing Instruments
Policy to provide standardized guidelines for written documentation. Written documentation is
scanned electronically and it is essential that scanned versions of documentation are readable.
All employees and physicians of AMGH will adhere to the following guidelines when handwriting
documentation in a healthcare record:
Ink Colour
Only use red, black or dark blue ink when documenting in a patient record
The following must not be used to document in a health record:
Any colour other those listed above
Rainbow colours
Pencils
Fountain pens
Highlighting
If you need to highlight, only use yellow highlighter
Yellow highlighted sections do not show the highlight but the documentation that was
highlighted remains clear
Colours other than a yellow highlighter will black out once scanned and the documentation
that was highlighted will be unreadable
Legibility
Light handwriting does not scan in a readable fashion so users are asked to apply some
pressure when documenting in the patient record, particularly when using a red pen
Ink Stamps
Discard any fading ink stamp and replace with new as faded stamps often do scan in a
readable fashion
PERFORMANCE MANAGEMENT
The Performance Management Plan is designed to be a year-round partnership between
employees and managers in the planning, coaching, reviewing, and rewarding of job performance.
A performance management plan will be conducted with each employee every one to two years
that allows input from employees about their development and goals.
31

ROADMAP TO EXCELLENCE
During our strategic planning session, we chose four priorities to focus on – People, Quality,
Finance and Integration. We have adopted a framework of Pillars to help us visualize these
priorities - just picture four tall stately Pillars that stand side by side while resting solidly on our
organization’s foundation of mission, vision, and values and hold up the AMGH roof. Remember
that Pillars = Strategic Priorities and Goals. Please be sure to check out the Pillar Wall located in
the Cafeteria.
Over the past year, we have launched the AMGH “Roadmap to Excellence” our map that sets out
best practices we believe are critical to achieving our strategic priorities and exceeding the metrics
that measure our success. It is a framework that aligns goals, aligns behaviors, and aligns
processes toward continuous improvement and achieving outcomes. It’s a work in progress and we
have rolled out training for many of these best practices to our leadership group first so they can
learn and practice and gain the added skills which will in turn support you when these best practices
are cascaded throughout the organization.
We are coming to the homestretch in completing our Clinical Services Plan and our Manpower Plan
which will then wrap up the final activity of our overall strategic planning process. Once the project
workgroup of clinicians, physicians, board members and leaders provide their feedback to the final
draft of the Plan, we are targeting to have it fully completed. Next steps will be selecting
recommendations and options to proceed with, setting up operational plans to implement, and
incorporating the goals into each of your performance management plans so that you can see how
your work contributes to the overall success of the organization. We have lots of important work in
front of us...lots of important work behind us...thanks to each of you who have participated and
contributed to this process! More to come on all of this – Stay tuned!
Clinical Services Plan
Areas of Focus
32

ROADMAP TO EXCELLENCE
AIDET
At Alexandra Marine and General Hospital, we know that our patients or visitors can be uncertain or
nervous. To help alleviate this, AMGH has adopted the AIDET concept. By consistently using
AIDET, our patients/visitors can feel confident in our abilities to provide excellent care.
Why AIDET
Accountability
Confidence
Decrease Anxiety
Informed
Human Factor
Opportunity
Relationship
Respect
Satisfaction
Standardize
Thanking People
Trust
33

ROADMAP TO EXCELLENCE
COMMUNICATION BOARD
Communications Boards are throughout the hospital in various departments. These boards are an
excellent communication tool to ensure staff have the information they need.
34

ROADMAP TO EXCELLENCE
Rounding for Outcomes
Rounding is a brief conversation that you have with your Manager/Vice President who will be asking
you specific questions each time. Rounding for Outcomes serves many purposes. Rounding
engages staff by asking them what is working well in their department, providing staff with ability to
recognize another co-worker, and allows the employee to provide suggestions for process
improvement.
Stoplight Reports
Stoplight reports provide staff with a overview of what the department has completed, what work is
still in progress and what cannot proceed at this time.
35

Roadmap to Excellence
Strategic Priorities 2015-2016
PEOPLE QUALITY INTEGRATION FINANCE
Increase in
staff &
physician
engagement
Link to
physician
and staff
survey
results from
January
2015
• Identify 2
action items to
focus on from
staff survey
• Identify 2
action items to
focus on from
physician
survey
Clinical Service &
Operational Plan
Implementation
of finalized plan
• Identify action items
to be completed in
2015/16 and
implement
QIP
• Decrease in falls
rates
Transformational
projects
EPIC Phase Two
• CVIS
• Implementation of
EPIC Phase 1
•Implementation
Elearning
•Meditech Server
Upgrade
Patient
Experience
•Improve patient
experience
•Share CSP priorities
and actions from
operational planning
•Establish patient
advisory council
Balanced Budget
Finish Year in
Balanced
Position
•Attendance
management
•Monthly reviews &
forecasting
•Overtime
Strategy
•Ensure aligns with
BPS guidelines
Working
Capital
•Improve working
capital
36

SERVICES
Cafeteria
The cafeteria is located in the basement. Cafeteria hours are 11:30 a.m. to 1:15 p.m. Monday to
Friday. The menu for lunch every day can be found in Docushare under Calendars. The cafeteria
has hot and cold lunch menu items, salads and sandwiches. After hours, the vending machine in
the cafeteria provides a variety of items.
A microwave and toaster are also available in the cafeteria 24/7. A cooler of water is located in the
cafeteria and there is a water / ice dispenser in the 2nd floor ward kitchen.
There is also a pop machine in the Emergency Department waiting area.
Refrigerator
A number of departments have refrigerators designated for staff; please ask your manager for more
information regarding your department. Please note that patient specific refrigerators are NOT to
be used for staff food.
Gift Shop
The Gift Shop is located just past the front doors of the building on the west side. It is completely
run by our volunteers, AMGH Auxiliary members. Generally the Gift Shop is open Monday to
Friday from 1:00 p.m. to 4:00 p.m., however can change. The Gift Shop offers new and interesting
items for purchase as well as chips and chocolate bars. There are many sales offered to staff at
different times of the year.
37

Lockers
There are male/female/general staff
locker rooms located in the
basement. If you wish to have a
locker, please contact the
Administrative Assistant, extension
5716.
The Emergency department has a
designated locker room. If you work
in the Emergency department you
will be assigned a locker on your first day.
Outside Electronics (that require electricity)
If you wish to bring in an outside electronic that requires being plugged into the building’s electrical
system, for example a fan for your office, you must have it approved by your manager and then
checked by maintenance staff for compliance with our systems before you use it. Please contact
maintenance by inputting a request into ServiceAnyware (please refer to page 25 for instructions on
how to use Service Anyware).
Parking / Bike Rack
Parking is limited at AMGH. We have a designated parking area for staff at the south side along
Montcalm street, parking spaces along the street and a designated parking lot. We ask our staff to
refrain from parking in our main parking lot located at the front of the hospital– particularly areas
close to building as well as the street parking on Cambria closest to Emergency entrance during
regular business hours - we do our best to keep these parking spots open for our patients and
visitors. Our parking lots are well lit at night, but unsupervised. Staff working evenings and nights
should park close to the hospital. Parking across from the Emergency entrance is best.
A bike rack is located on the south side of the building just beside the south entrance access door.
Staff Rooms / Washrooms
There are staff washrooms in the basement locker room which are card swipe access, central
basement corridor across from kitchen, back hallway across from MDRU, 2 nd floor nurses station,
Ambulatory Care nurses station, ER locker room in basement- card swipe access, 1 st floor just off of
ICU, Operating room staff lounge, 3 rd floor- beside the patient kitchen.
Public washrooms are located on 1 st floor across from the public elevator; in the basement in the
Emergency outpatient waiting area; and on 2 nd floor across from room 220 beside the Ambulatory
Care nurses station.
38

STARTING YOUR CAREER AT AMGH
Docushare
Non-patient related documentation is managed with software called Docushare. Docushare is
web-based software that houses thousands of documents. Docushare is one of the most commonly
used document management software programs in the world and is used by many hospitals and
School Boards as well as Bruce Power. Docushare helps us with document control and
compliance with the Freedom of Information and Protection of Privacy Act.
This powerful system has the ability to search through thousands of documents quickly and
accurately. The most current and up to date information resides in Docushare. Please refrain from
having multiple copies of printed forms or policies as changes can be made in Docushare and you
will no longer have the most current version. Please remember that a paper copy is no longer the
most current copy. Forms should be printed on an as needed basis, if possible.
All employees must be familiar with Docushare and be able to find valuable information. Take time to
explore the different collections. Know where to find:
Policies and Procedures
Emergency Planning Codes
MSDS Sheets
Committee Minutes
Hospital Memos
Staff Resources
Docushare Training notes are in Docushare under Staff Resources, Computer and Docushare Help.
For further Docushare training, please contact Crystal Dalton, Administrative Assistant/Systems
Development. You can contact her at Ext 5714 or crystal.dalton@amgh.ca to set up a time that is
suitable for you.
It is the responsibility of every employee to know where to find information within Docushare.
Dress Code
It is the policy of this organization to present an image to patients, visitors and the community that is
professional and inspires confidence. The overall presentation of staff members is an important
contributing factor to this image. Dress, grooming and conduct must be consistent with the work in
our professional work environment, health and safety regulations, infection control guidelines and
within the standards determined for optimum patient care. This policy also includes situations when
employees are attending hospital meetings, in-services and/or training sessions, etc.
The safety of our staff is a priority. Therefore, it is imperative that staff follow the footwear guidelines
in our Dress Code policy. It is mandatory that footwear have closed toe and heel, no sandals or
open-toed shoes. This applies to all staff and all areas of the organization including the community
offices. Any exceptions must be discussed and approved by Occupational Health / Infection Control.
39

Employee File
All employees files are kept in Docushare under restrictive access rights. If you require something
from your file or need to review it, please contact Human Resources, extension 5720.
Hours of Work
The organization is a 24/7 operation. Your hours of work will be scheduled by your manager and
vary by departmental needs. As shifts vary in length, unpaid and paid breaks also vary according to
their length; all staff are encouraged to take their breaks for their at work health.
Pay
Payroll is run bi-weekly Sunday to Saturday; paycheques are electronic funds transfers direct to your
bank account every other Thursday. Copies of paystubs are not automatically given to employees.
If you would like to print your paystub, please access Meditech, choose MOX, enter “99” and in the
PAY DATE box enter the date of deposit.
Also included on paystubs is your sick time and cost for the calendar year and N95 Mask Fit testing
date.
Photo ID
A photo identification badge will be given to new staff, volunteers and students
on their first day of orientation. It is mandatory that I.D. badges be visibly worn
at all times during working hours, above the waist, picture out so that patients,
visitors and other members of the organization can identify who you are.
I.D. badges are also used to sign into computer systems and afford access to
staff doors, such as staff entrances and staff washrooms.
Probation
All employees serve a probationary period. The time frame is dependent on
what, if any, union you may become a member. During this time, either the
employee or the Hospital may terminate employment without notice, as per the
Employment Standards Act of Ontario.
Probationary Review
A probationary review will be conducted with your manager before your probationary period ends.
Union / Non-Union
There are three unions at AMGH, Ontario Nurses’ Association, Service Employee’s International
Union (SEIU) and UNIFOR.
Union/Non-union staff are included in staff forums and correspondence and are always welcome to
speak to any member of the Executive Leadership Team; we have an open door policy for all of our
staff.
40

VIOLENCE / HARASSMENT
The Human Resources Advisor is the organizational lead for Violence in the Workplace and
Harassment. All policies and forms can be found in Docushare.
Harassment
AMGH is committed to providing a working environment in which all individuals (staff, physicians,
volunteers and visitors) are treated with respect and dignity. Each individual has the right to work in
an atmosphere which is fair, equitable and free from all forms of discrimination and harassment. It is
each person's responsibility to uphold these beliefs.
The purpose of this policy is to acknowledge that such conduct, contrary to this commitment, is
unacceptable and intolerable and will result in disciplinary actions up to and including the termination
of employment, with cause. Investigation of any complaints of harassment or discriminations will be
initiated within 72 hours. Staff who have a complaint must complete a Harassment Complaint Form
found in Docushare under Human Resources Policies.
Violence Prevention in the Workplace
AMGH is committed to providing a safe, healthy and supportive working environment by treating our
employees and patients with dignity, respect, care, and compassion. Violence in the workplace can
have devastating effects on the quality of life for our employees and on the productivity of the
organization. The management of AMGH recognizes the potential for violence in the workplace and
therefore will make every reasonable effort to identify all potential sources of violence to eliminate or
minimize these risks through the Workplace Violence Prevention program.
AMGH is committed to exhibiting a zero tolerance for violence, abusive, and aggressive behavior.
AMGH refuses to tolerate any type of workplace violence, within the workplace or at work-related
activities. AMGH is committed to the expenditure of time, attention, authority, and resources to
ensure a safe and healthy working environment for all employees and clients for whom we provide
care.
AMGH has a “zero tolerance” approach to workplace violence. “Zero Tolerance” means that every
reported action of abusive/aggressive or threatening behavior will be tracked and resolved based on
the individual facts. Individual cases may require different resolutions. Although measures will be put
in place to assist parties in conflict resolution, disciplinary action will be taken, where appropriate up
to and including termination of employment, revocation of physician's privileges or termination of
volunteer/student/contract agreements.
41

120 Napier St
Goderich, ON
N7A 1W5
519-524-8323
Visit us at
www.amgh.ca
You Can Count on Me
42